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WEST VIRGINIA SECONDARY SCHOOL ACTIVITIES COMMISSION

May 2015

2875 Staunton Turnpike - Parkersburg, WV 26104

ATHLETIC PARTICIPATION/PARENTAL CONSENT/PHYSICIAN’S CERTIFICATE FORM

(Form required each school year on or after June 1

. File in School Administration Office)

ATHLETIC PARTICIPATION / PARENTAL CONSENT

PART I

Name ___________________________________________________ School Year: __________ Grade Entering: ______________

(Last)

(First)

(M)

Home Address: ____________________________________________ Home Address of Parents: ___________________________

City: _____________________________________________________ City: _____________________________________________

Phone: _____________________ Date of Birth: _________________ Place of Birth: _____________________________________

Last semester I attended ________________________(High School) or (Middle School). We have read the condensed eligibility rules

of the WVSSAC athletics. If accepted as a team member, we agree to make every effort to keep up school work and abide by the rules

and regulations of the school authorities and the WVSSAC.

INDIVIDUAL ELIGIBILITY RULES

Attention Athlete! To be eligible to represent your school in any interscholastic contest, you ...

______ must be a regular bona fide student in good standing of the school. (See exception under Rule 127-2-3)

______ must qualify under the Residence and Transfer Rule (127-2-7)

______ must have earned at least 2 units of credit the previous semester. Summer School may be included. (127-2-6)

______ must have attained an overall “C” (2.00) average the previous semester. Summer School may be included. (127-2-6)

______ must not have reached your 15th (MS), 16th (9th) or 19th (HS) birthday before August 1 of the current school year. (127-2-4)

______ must be residing with parent(s) as specified by Rule 127-2-7 and 8.

______ unless parents have made a bona fide change of residence during school term.

______ unless an AFS or other Foreign-Exchange student (one year of eligibility only).

______ unless the residence requirement was met by the 365 calendar days attendance prior to participation.

______ if living with legal guardian/custodian, may not participate at the varsity level. (127-2-8)

______ must be an amateur as defined by Rule 127-2-11.

______ must have submitted to your principal before becoming a member of any school athletic team Participation/Parent Consent/Physician Form,

completely filled in and properly signed, attesting that you have been examined and found to be physically fit for athletic competition and that

your parents consent to your participation. (127-3-3)

______ must not have transferred from one school to another for athletic purposes. (127-2-7)

______ must not have received, in recognition of your ability as a HS or MS athlete, any award not presented or approved by your school or the

WVSSAC. (127-3-5)

______ must not, while a member of a school team in any sport, become a member of any other organized team or as an individual participant in an

unsanctioned meet or tournament in the same sport during the school sport season (See exception 127-2-10).

______ must follow All Star Participation Rule. (127-3-4)

______ must not have been enrolled in more than (8) semesters in grades 9 to 12. Must not have participated in more than two (2) seasons in the same

sport in grades 7 and 8 or more than three (3) seasons while in grades 6-7-8. (Rule 127-2-5).

______ must not have been retained without failing in grades 6, 7 or 8. (127-2-5)

Eligibility to participate in interscholastic athletics is a privilege you earn by meeting not only the above listed minimum standards but

also all other standards set by your school and the WVSSAC. If you have any questions regarding your eligibility or are in doubt about the effect

any activity or action might have on your eligibility, check with your principal or athletic director. They are aware of the interpretation and intent of each

rule. Meeting the intent and spirit of WVSSAC standards will prevent athletes, teams, and schools from being penalized.

PART II - PARENTAL CONSENT

In accordance with the rules of the WVSSAC, I give my consent and approval to the participation of the student named above for the sport NOT MARKED OUT BELOW:

BASEBALL

CROSS COUNTRY

GOLF

SOFTBALL

TENNIS

VOLLEYBALL

BASKETBALL

FOOTBALL

SOCCER

SWIMMING

TRACK

WRESTLING

CHEERLEADING

MEDICAL DISQUALIFICATION OF THE STUDENT-ATHLETE / WITHHOLDING A STUDENT-ATHLETE FROM ACTIVITY

The member school’s team physician has the final responsibility to determine when a student-athlete is removed or withheld from participation due to an

injury, an illness or pregnancy. In addition, clearance for that individual to return to activity is solely the responsibility of the member school’s team

physician or that physician’s designated representative.

I understand that participation may include, when necessary, early dismissal from classes and travel to participate in interscholastic athletic

contests. I will not hold the school authorities or West Virginia Secondary School Activities Commission responsible in case of accident or injury as a

result of this participation. I also understand that participation in any of those sports listed above may cause permanent disability or death. Please check

appropriate space: He/She has student accident insurance available through the school (

); has football insurance coverage available through the

school (

); is insured to our satisfaction (

I also give my consent and approval for the above named student to receive a physical examination, as required in Part IV, Physician’s Certificate,

of this form, by an approved health care provider as recommended by the named student’s school administration.

I consent to WVSSAC’s use of the herein named student’s name, likeness, and athletically related information in reports of Inter-School Practices or

Scrimmages and Contests, promotional literature of the Association, and other materials and releases related to interscholastic athletics.

I have read/reviewed the concussion information as available through the school and at . (Click Sports Medicine)

Date: ______________________________________________

Student Signature ________________________________________________

Parent Signature

________________________________________________

Athletic Participation/parental Consent/physician'S Certificate Form - West Virginia Secondary School Activities Commission

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